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THE CARIES-FREE MOUTH
587 Unless this is investigated and put right, the danger of mass neurosis arises : reprisal measures can only make matters worse. The assumption by the employer or medical board of an attitude of omniscience and infallibility can lead nowhere. The employer and doctor, by reason of their own inner anxieties, are frequently possessed themselves of a psychological blind spot, and so are often unable to see or comprehend the underlying causes of unrest, due in the last instance
value of their practices and in their houses and surgeries. Fair compensation must be given for these.
aware.
If the state is to attract the best in the profession it must find a solution to these problems, and lay down conditions of work and organisation which appeal to the profession as a whole. Only so can it hope to establish a fully efficient service ; and nothing less than this will satisfy the country. The difficulties are not of principle but of method and detail, and I hope and believe that a solution can be found for them on a basis of a wholetime salaried service. W. A. LISTER.
to difficult environmental factors. No man in his senses would expect his car to go forward when grit has got into the carburettor ; common sense would teach him first to extract the grit. If the - wheels of industry are to continue to revolve smoothly an exhaustive inquiry should be made into all the circumstances directly any tendency to a slowing down of effort manifests itself. A board should be constituted, comprising representatives both of employers and employees, assisted by a competent psychologist with The psycholoexperience of industrial disputes. gist is needed because his eye is specially trained to observe such matters and his therapeutic technique is devised to get rid of friction. CYRIL WILSON. Harley Street, W.I.
CONDITIONS OF MEDICAL SERVICE
SIR,-In your issue of Oct. 23
a group of correspondents of the specialist should not be higher than that attainable by the general practitioner by virtue of experience or higher qualifications." If this means that all doctors in the new state service are to be paid alike, regardless of whether they are consultants or general practitioners, many of us will protest. All consultants hold higher qualifications and these should carry higher rates of pay. I would suggest a basic pay for all. To this should be added allowances for (a) each extra diploma and (b) length of service. It might very properly be objected that it is more difficult to be a good general practitioner than a good consultant, but that few GPs desire to take a higher diploma (except perhaps MD) and so in fact would draw less pay than their colleagues in consulting practice with their many diplomas. Is it rash to suggest that a new diploma be instituted-a DGP (diploma in general practice) ? Or even a fourth Royal Collegea RCGP ? C. ELGOOD. Anne Street, W.l.
say that " the
salary
THROMBOCYTOPENIC PURPURA SIR,—We have read with much interest Mr. Rodney
Maingot’s letter of Oct. weights of the spleen in as
follows
23. some
We have available the of our cases. They are
:-
Queen
GOING UNDERGROUND SIR,—JJr. ivillials Uuipm, in his important letter in your issue of Sept. 25, raises the whole problem of the wrong and the right way of handling neurosis, whether of the individual or the mass variety as seen in industrial disputes. He illustrates from how small a beginning deep unrest may spring. Such knowledge cannot be too widely disseminated in time of war when stoppages of all sorts are catastrophic. Troubles are more liable to occur in war-time when the necessary deprivations and restrictions that accompany it cause men’s tempers to become frayed. The present rough-and-ready methods of handling disputes are to be deprecated together with the unfortunate tendency on the part of authority, whether such be medical or lay, to ignore the psychological side of things and try to push ahead blindly with production. In their stead should be introduced a realistic and humanitarian approach to such matters. Were this to come about we should all be the happier, individually and collectively, not to mention the speeding up in production that would ensue.
..
-
As Dr. Culpin says, the case of the lad Page illusOne trates the wrong way to handle such problems. who suffers from a fear of confined spaces should not be treated, without inquiry, as a malingerer or saboteur and forced to go down a pit, or even imprisoned for not doing so. In his case, it is stated that his fears had recently been reinforced by the sight of an older man brought up mangled from below. A difficult psychological relationship between son and father appears to lie behind such fear reactions and would need to be resolved by the state before it is entitled to ask him to become a miner. Consciously or unconsciously, the miners recognise this fact and protest against Page’s imprisonment, and the mishandling of his case by authority, in the only way that they know-by striking. To punish them in their turn is still more short-sighted and can only lead to widespread disaffection. There is too great a tendency for the lay mind to accuse the psychologist of " spoiling the child " when he advocates removal of the individual from the source of his fears. In industry generally, a strike threat is always the culminating sign of smouldering unrest-a protest on the part of the employee against some injustice that rankles, of which he may or may not be consciously ,
The two patients with the largest spleens (1 lb. 7 oz. and 1 lb. 2 oz.) were cured by splenectomy ; the third largest had splenculi, and hersymptoms persisted. There is no doubt about unremoved splenculi being a factor in relapse following splenectomy: but we have no evidence, either operative or necropsy, of splenculi being present in cases in our series apart from the ones we mentioned. HORACE EVANS. KENNETH M. A. PERRY. London Hospital, E.I. .
-
THE CARIES-FREE MOUTH
SIR,—At medical inspections of 544 children of different
age-groups
drawn from 15 schools in South London I careful search for and inquiries about caries-free mouths ; 6% of the children were caries-free, by which is meant, no caries present before or at the time of examination. Of the 5 to 6 age-group, 13% made
a
‘
7 9 11 13
" " " "
I have
figures
no
to to to to
8 10 12 14
" °
" "
were caries2%free.
2.2% 6% 5%
statistics for
are an
comparison but I believe these improvement on previous findings, and I’
submit them not for their intrinsic value, if any, but merely to call attention to the need for an inquiry into the reasons for this freedom from caries* Mellanby has shown that caries can be arrested and often prevented, but we still do not know why some children who eat what they like or what they can get have caries-free mouths. From a survey of my detailed notes I can do no more than form the impression that milk and/or cod-liver oil in adequate quantities, or the ability to tan, limit or prevent carious invasion, thus confirming in a haphazard way’ Mellanby’s findings. In the’ older caries-free children the presence of tartar was too constant to be disregarded. It may well be that caries-free children possess, manufacture or absorb something which other children lack, but at this stage it is wiser to make no comment. I would urge, however, that the study of caries-free
588 mouths by a team of dental surgeons, biochemists, dietitians and social workers might produce far-reaching results and do more to offset the shortage of dentists than schemes for increasing the supply. It would, I feel sure, prove the soundness of Professor Ryle’s constant appeal that the study of the healthy should keep pace with the study of the unfit. GUY NEELY. Blackheath. --
LEUCOCYTE
COUNTS IN RADIUM WORKERS SIR,—In your issue of Sept. 4 (p. 289) ur. U. j.u. Britton drew attention to a low level of leucocyte counts occurring among healthy nurses of the Middlesex Hospital, not exposed to radium. I have also noticedthis among nurses at Mount Vernon, and among normal young males beginning_ radium work and not connected with any hospital. It seems likely that this is a war-time effect, worth the while of some public body like the Ministry of Health to investigate, to see how far it egterids in the population, and -to seek its cause. It is to be noted in Britton’s counts that whereas 20’1% were below the level of 3000 polymorphs per c.mm., only 8-1% were below the level of 1500 lymphocytes. Thus the lymphocytes are much less effected. So by discarding the polymorph count and relying on the lymphocyte, it remains possible to rely upon blood-counts to determine whether workers should or should not continue handling X rays and radium. Several radium workers under my care have recently shown progressive falls in polymorph counts not accompanied by lymphocyte falls, and have been permitted to continue with their work. I do not agree with Britton that weekly counts would solve the difficulty. Among radium workers the fall in leucocytes -is to be detected not in weeks but in months .or years, and could not thus be distinguished from the war-time effect to which he draws attention. J. C. MOTTRAM. Mount Vernon Hospital, Northwood. THE
SIZE
HIPPURIC-ACID EXCRETION AND URINE VOLUME SIR,—In your issue of Oct. 16 Major Allan Palmer, confirming the findings of Machella et al., reports a positive correlation between the amount of hippuric acid (HA) excretion and urine volume, using Quick’s intraThis was evident venous modification of the test. particularly in tests where the urine volume was below 150 c.cm. and he concludes that abnormally low HA values obtained in a urine volume below 150 c.cm. may be inaccurate. This conclusion, on the evidence presented, is open- to criticism. It is a well-established fact/ not mentioned by either investigator, that patients with hepatic disturbances have a tendency to delayed excretion of water and oliguria. One would expect, therefore, to find a tendency to low urine volumes in association with low excretion of HA, both presumably being related to the same underlying disorder. In my experience with the intravenous modification of the test, using Weichselbaum and Probstein’s (1939) analytical technique, and giving 200,c.cm. of water at the time of the injection (as is recommended by Dr. Palmer), many patients and normals show " normal " and even " optimal " excretion of HA in the first hour despite urine volumes below 150 c.cm. and even below 100 c.cm. To consider a subnormal output of HA in a " low " urine volume as " inaccurate " seems to me objectionable, since the frequent association of low urine volumes with low HA output does not necessarily imply that the one directly causes the other. In fact, while I find, on plotting excretion of HA against volume in some 180 tests, a certain tendency for the low HA values to be associated with low urine volumes, the correlation is not strict. In follow-up studies with serial tests in individual patients the lack of correlation is striking, and it becomes clear that a large urine volume need not cause an increase in the output of HA or vice versa. To illustrate this may I quote the following data from five patients with gastric ulcer :
OF INFLUENZA A VIRUS
SIR,—Dr. Kenneth Smith’s letter in your issue of Oct. 23 prompts me to mention briefly some experiments conducted, in collaboration with the late Miss Dora Lush, soon after American workers first intimated that they regarded the true size of influenza virus to be about 15 mµ. This figure was the outcome of studies with the virus propagated in 10-day-old hens’ eggs, whereas earlier work with the virus obtained from the lungs of flu-infected mice had indicated a particle size 80-100 mµ. We accordingly analysed allantoic and amniotic fluids from eggs infected with influenza A virus, employing the methods of ultrafiltration and centrifugation. During the limited attention we could devote to the problem at that time, no evidence was found for the existence of the extremely small phase of the virus. Likewise, virus that had been precipitated with salmine and re-dispersed .
showed the same order of size as virus before such treatment. It should also be mentioned that Friedewald and Pickles (Proc. Soc. exp. Biol. Med. 1943, 52, 261) have recently reported having submitted influenza-infected allantoic fluid to centrifugation analysis, and, following a different technique from our own, find the size of the virus to be at least 60 my. Our values by two alternative centrifugation methods ranged from 60 to 90 m,u. In my opinion, you were wholly justified in your criticism of the hasty acceptance of the small figure for the size of influenza virus by Dr. Smith in his generally admirable booklet Beyond the Microscope. National Institute for Medical Research, N.W.3.
W. J. ELFORD.
* * Current opinion as to the size of viruses is based upon the results of differential filtration through graded collodion membranes, centrifugation and at times optical methods ; data so obtained by these three methods have on the whole yielded concordant results. Chambers and Henle have recently thrown doubt on the conclusions thus reached as to the size of influenza virus. The exact size of this virus is in itself relatively unimportant, but their claims, if correct, throw doubt on most of what is now accepted as to the sizes of viruses in general. The claims have, however, not yet carried general conviction, especially in this country.-ED. L.
*
Post-oP.
The observation of Machella et al. that induction of diuresis by say 1000 c.cm. of water before the test may increase the output of HA, requires closer study since no account was taken of possible spontaneous day-to-day variations in an upward direction. H. POLLAK. NOT SO DREARY
pitals controlled by the Middlesex County Council are admittedly excellent, but by no stretch of imagination can they be considered representative of the conditions prevailing in municipal hospitals throughout the country. The rateable value of the county of Middlesex, is the highest in the world ; therefore considerably more money is available for hospital development. In the majority of municipal hospitals the position of the senior members of the staff has deteriorated steadily since the outbreak of
war
and
favourably with the position practitioners.
now
of the
compares very
un-
majority of general
I do not propose to waste space by going through the list of amenities mentioned in the letter of Dr. Avery Jones in your issue of Oct. 23, but I can safely say that in the average municipal hospital not one of them would be found to exist. ASSISTANT MEDICAL OFFICER. 1. Adler, A. Klin. Wschr. 1923, 2, Arch. inn. Med. 1934, 25, 269.
1980 ; Adlersberg, D. Wien.
value of their practices and in their houses and surgeries. Fair compensation must be given for these.
aware.
If the state is to attract the best in the profession it must find a solution to these problems, and lay down conditions of work and organisation which appeal to the profession as a whole. Only so can it hope to establish a fully efficient service ; and nothing less than this will satisfy the country. The difficulties are not of principle but of method and detail, and I hope and believe that a solution can be found for them on a basis of a wholetime salaried service. W. A. LISTER.
to difficult environmental factors. No man in his senses would expect his car to go forward when grit has got into the carburettor ; common sense would teach him first to extract the grit. If the - wheels of industry are to continue to revolve smoothly an exhaustive inquiry should be made into all the circumstances directly any tendency to a slowing down of effort manifests itself. A board should be constituted, comprising representatives both of employers and employees, assisted by a competent psychologist with The psycholoexperience of industrial disputes. gist is needed because his eye is specially trained to observe such matters and his therapeutic technique is devised to get rid of friction. CYRIL WILSON. Harley Street, W.I.
CONDITIONS OF MEDICAL SERVICE
SIR,-In your issue of Oct. 23
a group of correspondents of the specialist should not be higher than that attainable by the general practitioner by virtue of experience or higher qualifications." If this means that all doctors in the new state service are to be paid alike, regardless of whether they are consultants or general practitioners, many of us will protest. All consultants hold higher qualifications and these should carry higher rates of pay. I would suggest a basic pay for all. To this should be added allowances for (a) each extra diploma and (b) length of service. It might very properly be objected that it is more difficult to be a good general practitioner than a good consultant, but that few GPs desire to take a higher diploma (except perhaps MD) and so in fact would draw less pay than their colleagues in consulting practice with their many diplomas. Is it rash to suggest that a new diploma be instituted-a DGP (diploma in general practice) ? Or even a fourth Royal Collegea RCGP ? C. ELGOOD. Anne Street, W.l.
say that " the
salary
THROMBOCYTOPENIC PURPURA SIR,—We have read with much interest Mr. Rodney
Maingot’s letter of Oct. weights of the spleen in as
follows
23. some
We have available the of our cases. They are
:-
Queen
GOING UNDERGROUND SIR,—JJr. ivillials Uuipm, in his important letter in your issue of Sept. 25, raises the whole problem of the wrong and the right way of handling neurosis, whether of the individual or the mass variety as seen in industrial disputes. He illustrates from how small a beginning deep unrest may spring. Such knowledge cannot be too widely disseminated in time of war when stoppages of all sorts are catastrophic. Troubles are more liable to occur in war-time when the necessary deprivations and restrictions that accompany it cause men’s tempers to become frayed. The present rough-and-ready methods of handling disputes are to be deprecated together with the unfortunate tendency on the part of authority, whether such be medical or lay, to ignore the psychological side of things and try to push ahead blindly with production. In their stead should be introduced a realistic and humanitarian approach to such matters. Were this to come about we should all be the happier, individually and collectively, not to mention the speeding up in production that would ensue.
..
-
As Dr. Culpin says, the case of the lad Page illusOne trates the wrong way to handle such problems. who suffers from a fear of confined spaces should not be treated, without inquiry, as a malingerer or saboteur and forced to go down a pit, or even imprisoned for not doing so. In his case, it is stated that his fears had recently been reinforced by the sight of an older man brought up mangled from below. A difficult psychological relationship between son and father appears to lie behind such fear reactions and would need to be resolved by the state before it is entitled to ask him to become a miner. Consciously or unconsciously, the miners recognise this fact and protest against Page’s imprisonment, and the mishandling of his case by authority, in the only way that they know-by striking. To punish them in their turn is still more short-sighted and can only lead to widespread disaffection. There is too great a tendency for the lay mind to accuse the psychologist of " spoiling the child " when he advocates removal of the individual from the source of his fears. In industry generally, a strike threat is always the culminating sign of smouldering unrest-a protest on the part of the employee against some injustice that rankles, of which he may or may not be consciously ,
The two patients with the largest spleens (1 lb. 7 oz. and 1 lb. 2 oz.) were cured by splenectomy ; the third largest had splenculi, and hersymptoms persisted. There is no doubt about unremoved splenculi being a factor in relapse following splenectomy: but we have no evidence, either operative or necropsy, of splenculi being present in cases in our series apart from the ones we mentioned. HORACE EVANS. KENNETH M. A. PERRY. London Hospital, E.I. .
-
THE CARIES-FREE MOUTH
SIR,—At medical inspections of 544 children of different
age-groups
drawn from 15 schools in South London I careful search for and inquiries about caries-free mouths ; 6% of the children were caries-free, by which is meant, no caries present before or at the time of examination. Of the 5 to 6 age-group, 13% made
a
‘
7 9 11 13
" " " "
I have
figures
no
to to to to
8 10 12 14
" °
" "
were caries2%free.
2.2% 6% 5%
statistics for
are an
comparison but I believe these improvement on previous findings, and I’
submit them not for their intrinsic value, if any, but merely to call attention to the need for an inquiry into the reasons for this freedom from caries* Mellanby has shown that caries can be arrested and often prevented, but we still do not know why some children who eat what they like or what they can get have caries-free mouths. From a survey of my detailed notes I can do no more than form the impression that milk and/or cod-liver oil in adequate quantities, or the ability to tan, limit or prevent carious invasion, thus confirming in a haphazard way’ Mellanby’s findings. In the’ older caries-free children the presence of tartar was too constant to be disregarded. It may well be that caries-free children possess, manufacture or absorb something which other children lack, but at this stage it is wiser to make no comment. I would urge, however, that the study of caries-free
588 mouths by a team of dental surgeons, biochemists, dietitians and social workers might produce far-reaching results and do more to offset the shortage of dentists than schemes for increasing the supply. It would, I feel sure, prove the soundness of Professor Ryle’s constant appeal that the study of the healthy should keep pace with the study of the unfit. GUY NEELY. Blackheath. --
LEUCOCYTE
COUNTS IN RADIUM WORKERS SIR,—In your issue of Sept. 4 (p. 289) ur. U. j.u. Britton drew attention to a low level of leucocyte counts occurring among healthy nurses of the Middlesex Hospital, not exposed to radium. I have also noticedthis among nurses at Mount Vernon, and among normal young males beginning_ radium work and not connected with any hospital. It seems likely that this is a war-time effect, worth the while of some public body like the Ministry of Health to investigate, to see how far it egterids in the population, and -to seek its cause. It is to be noted in Britton’s counts that whereas 20’1% were below the level of 3000 polymorphs per c.mm., only 8-1% were below the level of 1500 lymphocytes. Thus the lymphocytes are much less effected. So by discarding the polymorph count and relying on the lymphocyte, it remains possible to rely upon blood-counts to determine whether workers should or should not continue handling X rays and radium. Several radium workers under my care have recently shown progressive falls in polymorph counts not accompanied by lymphocyte falls, and have been permitted to continue with their work. I do not agree with Britton that weekly counts would solve the difficulty. Among radium workers the fall in leucocytes -is to be detected not in weeks but in months .or years, and could not thus be distinguished from the war-time effect to which he draws attention. J. C. MOTTRAM. Mount Vernon Hospital, Northwood. THE
SIZE
HIPPURIC-ACID EXCRETION AND URINE VOLUME SIR,—In your issue of Oct. 16 Major Allan Palmer, confirming the findings of Machella et al., reports a positive correlation between the amount of hippuric acid (HA) excretion and urine volume, using Quick’s intraThis was evident venous modification of the test. particularly in tests where the urine volume was below 150 c.cm. and he concludes that abnormally low HA values obtained in a urine volume below 150 c.cm. may be inaccurate. This conclusion, on the evidence presented, is open- to criticism. It is a well-established fact/ not mentioned by either investigator, that patients with hepatic disturbances have a tendency to delayed excretion of water and oliguria. One would expect, therefore, to find a tendency to low urine volumes in association with low excretion of HA, both presumably being related to the same underlying disorder. In my experience with the intravenous modification of the test, using Weichselbaum and Probstein’s (1939) analytical technique, and giving 200,c.cm. of water at the time of the injection (as is recommended by Dr. Palmer), many patients and normals show " normal " and even " optimal " excretion of HA in the first hour despite urine volumes below 150 c.cm. and even below 100 c.cm. To consider a subnormal output of HA in a " low " urine volume as " inaccurate " seems to me objectionable, since the frequent association of low urine volumes with low HA output does not necessarily imply that the one directly causes the other. In fact, while I find, on plotting excretion of HA against volume in some 180 tests, a certain tendency for the low HA values to be associated with low urine volumes, the correlation is not strict. In follow-up studies with serial tests in individual patients the lack of correlation is striking, and it becomes clear that a large urine volume need not cause an increase in the output of HA or vice versa. To illustrate this may I quote the following data from five patients with gastric ulcer :
OF INFLUENZA A VIRUS
SIR,—Dr. Kenneth Smith’s letter in your issue of Oct. 23 prompts me to mention briefly some experiments conducted, in collaboration with the late Miss Dora Lush, soon after American workers first intimated that they regarded the true size of influenza virus to be about 15 mµ. This figure was the outcome of studies with the virus propagated in 10-day-old hens’ eggs, whereas earlier work with the virus obtained from the lungs of flu-infected mice had indicated a particle size 80-100 mµ. We accordingly analysed allantoic and amniotic fluids from eggs infected with influenza A virus, employing the methods of ultrafiltration and centrifugation. During the limited attention we could devote to the problem at that time, no evidence was found for the existence of the extremely small phase of the virus. Likewise, virus that had been precipitated with salmine and re-dispersed .
showed the same order of size as virus before such treatment. It should also be mentioned that Friedewald and Pickles (Proc. Soc. exp. Biol. Med. 1943, 52, 261) have recently reported having submitted influenza-infected allantoic fluid to centrifugation analysis, and, following a different technique from our own, find the size of the virus to be at least 60 my. Our values by two alternative centrifugation methods ranged from 60 to 90 m,u. In my opinion, you were wholly justified in your criticism of the hasty acceptance of the small figure for the size of influenza virus by Dr. Smith in his generally admirable booklet Beyond the Microscope. National Institute for Medical Research, N.W.3.
W. J. ELFORD.
* * Current opinion as to the size of viruses is based upon the results of differential filtration through graded collodion membranes, centrifugation and at times optical methods ; data so obtained by these three methods have on the whole yielded concordant results. Chambers and Henle have recently thrown doubt on the conclusions thus reached as to the size of influenza virus. The exact size of this virus is in itself relatively unimportant, but their claims, if correct, throw doubt on most of what is now accepted as to the sizes of viruses in general. The claims have, however, not yet carried general conviction, especially in this country.-ED. L.
*
Post-oP.
The observation of Machella et al. that induction of diuresis by say 1000 c.cm. of water before the test may increase the output of HA, requires closer study since no account was taken of possible spontaneous day-to-day variations in an upward direction. H. POLLAK. NOT SO DREARY
pitals controlled by the Middlesex County Council are admittedly excellent, but by no stretch of imagination can they be considered representative of the conditions prevailing in municipal hospitals throughout the country. The rateable value of the county of Middlesex, is the highest in the world ; therefore considerably more money is available for hospital development. In the majority of municipal hospitals the position of the senior members of the staff has deteriorated steadily since the outbreak of
war
and
favourably with the position practitioners.
now
of the
compares very
un-
majority of general
I do not propose to waste space by going through the list of amenities mentioned in the letter of Dr. Avery Jones in your issue of Oct. 23, but I can safely say that in the average municipal hospital not one of them would be found to exist. ASSISTANT MEDICAL OFFICER. 1. Adler, A. Klin. Wschr. 1923, 2, Arch. inn. Med. 1934, 25, 269.
1980 ; Adlersberg, D. Wien.